Dysfunctional uterine bleeding
This diagnosis should be used only when all organic causes are ruled-out, which generally does not occur in the ED. See nonpregnant vaginal bleeding for the general approach.
Background
Vaginal Bleeding Definitions
- Menorrhagia: >7 day (prolonged) or >80 mL/day (excessive) uterine bleeding at regular intervals
- Metrorrhagia: irregular vaginal bleeding outside the normal cycle
- Menometrorrhagia - Excessive irregular vaginal bleeding
- Intermenstrual bleeding - variable amounts between regular menstrual periods
- Midcycle spotting - spotting just before ovulation (due to decline in estrogen)
- Postmenopausal bleeding - recurrence of bleeding after menopause
- Never normal but usually not emergency, requires outpatient OB/GYN follow up
- Polymenorrhea: Frequent and light bleeding
- Postcoital bleeding: vaginal bleeding after intercourse, suggesting cervical pathology
- Postmenopausal bleeding: Any bleeding that occurs >6 mo after cessation of menstruation
- The International Federation of Gynecology and Obstetrics (FIGO) introduced a new classification system known by the acronym PALM-COEIN
- PALM: structural causes
- Polyp (AUB-P)
- Adenomyosis (AUB-A)
- Leiomyoma (AUB-L)
- Malignancy and hyperplasia (AUB-M)
- COEIN: nonstructural causes
- Coagulopathy (AUB-C)
- Ovulatory dysfunction (AUB-O)
- Endometrial (AUB-E)
- Iatrogenic (AUB-I)
- Not yet classified (AUB-N)
Clinical Features
Differential Diagnosis
Nonpregnant Vaginal Bleeding
Systemic Causes
- Cirrhosis
- Coagulopathy (Von Willebrand disease, ITP)
- Group A strep vaginitis (prepubertal girls)
- Hormone replacement therapy
- Hypothyroidism
- Secondary anovulation
Reproductive Tract Causes
- Adenomyosis
- Atrophic endometrium
- Dysfunctional uterine bleeding
- Endometriosis
- Fibroids
- Foreign Body
- Infection (vaginitis, PID)
- IUD
- Neoplasia
- Vaginal Trauma
Evaluation
- See nonpregnant vaginal bleeding for general approach
- This diagnosis generally requires a endocervical curettage/endometrial biopsy to have been performed
Management
Heavy bleeding
- Fluid admin
- Estrogen-progestin OCP until gyn follow up
Severe Bleeding
- Maintain hemodynamics
- Consider IV conjugated estrogen (Premarin) 25mg IV q4-6 hrs until bleeding stops
- Continued severe bleeding requires D&C
References
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